Clinical Appeals Review and Compliance Specialist (PharmD)

MedImpact Healthcare Systems, Inc.•San Diego, CA

3d•Onsite

About The Position

MedImpact Healthcare Systems, Inc. is seeking an extraordinary Clinical Appeals Review & Compliance Specialist to join their team. This role serves as a clinical and operational support resource for the Appeals Clinical Team, reporting directly to the Appeal and Grievance Supervisor, Clinical Programs. The position is responsible for reviewing Appeals for commercial and Part D, rendering determinations based on established clinical guidelines, plan criteria, regulatory requirements, documented procedures, and clinical judgment. The specialist will assist the clinical team with appeal processing questions and issue resolution, track assigned work queues, identify volume fluctuations, and communicate workflow concerns to management. This role works closely with the Appeals and Grievances Supervisor, Clinical Programs and the Management Team to identify and escalate issues, and provide feedback regarding process observations. Responsibilities include providing clinical training, supporting the implementation of appeal process updates, and completing other operational tasks as determined by the Supervisor. This is an internal and external client-facing position requiring excellent customer service and communication skills.

Requirements

PharmD and 3+ years’ experience or equivalent combination of education and experience
1 year of SME in respective areas
Knowledge of Microsoft Office Suite
Working knowledge of relational databases
Current, unrestricted license as a Registered Pharmacist in any state of the United States required.
Data analysis and claims research experience preferred.
Capability to work with complex systems and analyze data for trends.
Analytical skills with Health Informatics experience preferred.
Experience in promoting disease management or drug cost management programs preferred.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.
Ability to apply concepts of basic algebra and geometry.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.
Ability to write reports, business correspondence, and procedure manuals.
Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Composure
Decision Quality
Organizational Agility
Problem Solving
Customer Focus
Drive for Results
Peer Relations
Time Management
Dealing with Ambiguity
Learning on the Fly
Political Savvy

Nice To Haves

Data analysis and claims research experience
Health Informatics experience
Experience in promoting disease management or drug cost management programs

Responsibilities

Serves as a clinical reviewer and provides subject matter support to the Appeals Clinical team.
Able to perform independent research of available medical literature, internal and external guidelines, compendium sources of drug information, and plan benefit documents to render appeal determinations.
Perform retrospective case review for appropriateness as required by management team.
Assist Supervisor with PA audit team and other internal teams to investigate and respond to appeal determination questions relevant to commercial and CMS Part D activity.
Assists the Supervisor with the completion of CMS client audits as needed.
Assists with issues directly related to clinical appeal processing and review as needed.
Develops capability to use all MedImpact systems relevant to the appeal clinical review requirements.
Other duties as assigned including, but not limited to, representing Appeals and Grievance in internal and external meetings related to appeals processing and as approved by management.